| NPI | 1376641605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TM1800X Psychologist, Intellectual & Developmental Disabilities (Licence: MN LP #1603) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MN LP #1603) |
| 103TC1900X Psychologist, Counseling (Licence: MN LP #1603) | |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2014-07-16 |